Westminster Village Kentuckiana
2210 Greentree N, Clarksville, IN 47129 · Government - County · 94 certified beds · (812) 282-5911 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited Sep 2025
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.5% | 11.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.9% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 4.6% | 1.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.6% | 25.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.9% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.6% | 11.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.2% | 23.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.4% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.1% | 3.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.9% | 23.3% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 17.0% | 13.6% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 73.3% | 79.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 30.6% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.1% | 10.8% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.48 | 1.61 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.27 | 1.44 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 86 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 60 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.88 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.4%CMS range 45.2–61.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 15.8%CMS range 12.0–19.9 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 56.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 45.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 7.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.9%CMS range 5.4–14.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.21 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 94 beds and averages 66.2 residents a day — about 70% occupied, or roughly 28 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.68 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.57 hrs/resident/day on weekends vs 4.34 on weekdays — 18% thinner on weekends. RN hours go from 0.72 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Fcited before2026-06-23 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner related to the drywall hanging down and gaps in construction for 1 of 1 kitchen observations. This deficient practice had the potential to affect 64 of 65 residents residing in the facility. Findings include:On 6/23/26, between 8:30 a.m. and 9:15 a.m., the following was observed in the kitchen: -The ceiling to the left of the food prep table had a taped area that was dislodged with a 4-inch gap. The drywall was hanging down from the area,-A piece of board that had been nailed to the ceiling, measuring 3 feet by 3 feet, was observed bowing on two different sides with a 2-inch gap which was located over a food prep table. A 4-slice toaster was observed directly under it.During an interview on 6/23/26 at 9:03 a.m., the Dietary Manager indicated maintenance staff pulled it down and did not tape it back up. She mentioned it in the morning meeting last Friday, 6/19/26, and it was still hanging down today. On 6/22/26 at 12:56 p.m., the healthcare Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-23 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pest control services were timely and effective. This deficient practice had the potential to affect 65 of 65 residents residing in the facility. Findings include: On 6/23/26 at 11:00 a.m., the pest activity logs were reviewed and indicated the following pest concerns:- rooms [ROOM NUMBERS], staff reported weird looking bugs on 3/7/26- Admissions office, staff reported ants on 3/9/26A- room [ROOM NUMBER], family reported ants on 3/23/26- room [ROOM NUMBER], staff reported ants on 4/28/26- room [ROOM NUMBER], staff reported ants on 5/15/26- room [ROOM NUMBER], staff reported ants on 5/18/26- room [ROOM NUMBER], roaches were reported on 5/19/26- room [ROOM NUMBER], staff reported bugs on 6/8/28- room [ROOM NUMBER], staff reported ants on 6/23/26Review of the pest control treatment services indicated the facility pest service treated the facility on 1/20/26 and 5/11/26.The pest control treatment services lacked documentation of which resident rooms…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility to ensure the kitchen equipment, floors, and meal carts were clean and sanitary. This deficient practice affected 64 of 64 residents who currently received meals from the kitchen.Findings Include:1.During the initial kitchen tour, on 1/13/26 at 9:00 a.m., the following areas of concern were observed: -The dish machine had three areas of long white lime streaks going down the front of the dish washer.-The steam table machine had a heavy soil of yellow, brown and black material inside the two doors at the bottom. The same soil was observed along the sliding edge of the two doors and along the edge below the five control knobs.-Inside the two closed food carts, there were multiple brown and white spills on the bottom of the carts. One cart had lunch trays set up waiting for the food.-The floor underneath the flat top grill, had multiple brown spills and grease on it.-The fryer had a moderate amount of brown particles in the oil and along the inside shelf of the fryer. The fryer was greasy and sticky to the touch along the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-01-20 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure glucometers were cleaned per guidelines for infection control when obtaining blood sugar readings for 4 of 4 residents observed for glucometer use. (Residents 71, 45, 33, and 7)Findings include:1. During an observation, on 1/14/26 at 10:59 a.m., Licensed Practical Nurse (LPN) 4 indicated that each resident had their own glucometer. The LPN entered Resident 71's room and completed the accu-check (blood sugar monitoring). The resident's blood sugar reading indicated 296 milligrams per deciliter (mg/dL). The LPN administered the required dosage of Lispro insulin. The LPN had placed the glucometer back into the resident's glucometer holder in the top drawer of the medication cart, without cleaning it. There was no visible blood or stains on the glucometer. During an interview, on 1/14/26 at 11:02 a.m., LPN 4 indicated the glucometers were usually cleaned after he had obtained all of each resident's blood sugar readings during the day. I can clean it if you want me to. He obtained the Sani-Cloth wipe and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents' choices for likes, dislikes and requests for special food items on their food trays cards were honored at every meal. This deficient practice affected 19 of 64 residents reviewed for tray cards. (Residents 7, 8, 9, 10, 13, 17, 20, 34, 38, 40, 51, 55, 57, 58, 62, 63 , 64, 65, and 66) Findings include:During an interview with Resident 7 on 1/13/26 at 9:45 a.m., she indicated that she frequently did not receive what was ordered on her tray card.During an interview with Resident 51 on 1/13/26 at 9:50 a.m., she indicated the kitchen was not following what was written on their tray cards. She indicated that her tray card, under dislikes, listed No Sausage or Eggs, but she still received them every morning anyway. She sent them back every time as she did not eat them. Observation of her tray card at this time, indicated sausage and eggs were listed under the dislike section. Observation of her plate indicated she received sausage and eggs for breakfast.During an observation of the main dining room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of urine received the necessary care and services of brief changes before the brief and bed padding underneath the resident was not overly saturated with urine for 1 of 4 residents reviewed for Activities of Daily Living. (Resident 13)Findings include:During an observation, on 1/13/26 at 10:00 a.m., upon entering Resident 13's room, there was a strong odor of urine and feces present. Observation of Resident 13 in bed, indicated the resident was lying on a draw pad under her which was observed to have a light brown stain that covered the whole pad, within an inch of the edges. The resident's brief and pad was observed to be saturated with urine. A second observation of the resident's room, on 1/13/26 at 2:30 p.m., the soiled pad remained on her bed and was still wet to the touch. The resident was in an activity at this time.During an observation of the resident and her bed, from 1/14/26 to 1/21/26, with a confidential informant, the resident's brief was observed to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with a history of Urinary Tract Infections (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system off the floor for 1 of 4 residents reviewed for bowel and bladder. (Resident 33)Findings include:During an observation, on 1/13/25 between 12:00 p.m. and 1:00 p.m., Resident 33 had been in the dining room for 60 minutes with her urinary catheter collection bag and tubing sitting on the floor. The resident had been rolling in her wheelchair back and forth across the catheter tubing with the wheelchair wheels. There were multiple staff members in the dining room at that time. During an observation, on 1/15/26 at 8:30 a.m., Resident 33 was lying in bed and just finished eating her breakfast. Her foley catheter was sitting on the floor with no barrier between the indwelling urinary catheter collection bag and the floor.During an observation, on 1/15/25 at 1:00 p.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-20 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure residents were provided with the adaptive equipment necessary to maintain independence while eating or drinking for 1 of 1 resident who utilized adaptive feeding equipment reviewed. (Resident 9)Findings include: During a dining room observation, on 1/13/26 at 12:50 p.m., the tray card for Resident 9 indicated he was to have a two handled cup for liquids. No two handled cup was present and he was drinking from plastic cups with no handles for his tea and water.An interview with the Staff Coordinator, on 1/13/26 at 1:00 p.m., she indicated as far as she knew, the resident did not require any specific adaptive devices at meal times.During a second observation of the dining room on 1/16/26 at 12:45 p.m., Resident 9 was observed drinking his shake, water and tea from a regular plastic cup. No two handled cups were in sight.The record for Resident 9 was reviewed on 1/16/2026 at 1:39 p.m., The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, transient cerebral ischemic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for misappropriation. (Resident B)Findings include:The clinical record for Resident B was reviewed on 9/2/25 at 2:24 p.m. The resident's diagnoses included, but were not limited to, diabetes, depression and chronic pain.The physician's order, dated 6/3/25, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every 6 hours as needed for pain.Review of the pharmacy delivery receipt, dated 8/16/25 at 6:45 p.m., indicated the resident's 30 Hydrocodone-Apap (acetaminophen) 5-325 mg were delivered and signed for by LPN 6.The incident report, dated 8/16/25, indicated on 8/19/25 Registered Nurse (RN) 7 called the pharmacy to find out why a narcotic medication that was ordered for Resident B had not been delivered. The pharmacy reported that 30 tablets of the narcotic pain medication was delivered on 8/16/25. The pharmacy sent over the signature page which showed the narcotic pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure an assessment was completed by a licensed nurse and authorization given to administer an as needed narcotic pain medication by a qualified medication aide for 1 of 3 residents reviewed for quality of care. (Resident C)Findings include:The clinical record for Resident C was reviewed on 9/3/25 at 9:55 a.m. The resident's diagnoses included, but were not limited to, fibromyalgia, depression and pain.The physician's order, dated 6/20/25, indicated the resident was to receive oxycodone with acetaminophen (narcotic pain medication) 7.5 mg (milligrams) every 4 hours as needed for pain.The August controlled drug record indicated the resident received the as needed pain medication on the following dates and times by Qualified Medication Aide (QMA) 10: 7/31/25 at 8:00 p.m., 8/01/25 at 12:00 a.m. and 4:00 a.m., 8/09/25 at 9:15 p.m., 8/10/25 at 12:30 a.m., 4:00 a.m. and 8:00 p.m., 8/11/25 at 12:00 a.m. and 4:00 a.m., 8/13/25 at 9:00 p.m., 8/14/25 at 12:00 a.m., 4:00 a.m. and 8:00 p.m., 8/15/25 at 12:00 a.m. and 4:00 a.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Dcited before2025-09-04 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident's (Resident C) medication administration record accurately reflected the administration of narcotic pain medication for 1 of 3 residents reviewed for documentation.Findings include: The clinical record for Resident C was reviewed on 9/3/25 at 9:55 a.m. The resident's diagnosis included, but was not limited to, fibromyalgia.The physician's order, dated 6/20/25, indicated the resident was to receive oxycodone with acetaminophen, 7.5 mg (milligrams) every 4 hours as needed for pain.The August 2025 controlled drug record indicated the resident received the medication on the following dates and times:-8/02/25 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/03/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m. and 4:00 p.m.-8/08/25 at 10:00 p.m.-8/09/25 at 2:00 a.m., 6:00 a.m., 10:15 a.m., 2:15 p.m. and 9:15 p.m.-8/10/25 at 12:30 a.m. and 12:00 p.m.-8/11/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/12/25 at 12:00 a.m., 4:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/13/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide a clean and sanitary kitchen. This had the potential to affect 59 of 59 residents that received food from the kitchen. Findings include: On 1/21/25, between 11:35 a.m. and 12:03 p.m., the following concerns were observed in the kitchen: -Upon entrance to the dry storage area and to the left, rodent droppings and jelly packets were observed behind the shelves along the wall. -Behind the shelving, on the right side of the storage area, rodent droppings and condiment packets were observed. -Under the shelf where the large canned foods were kept was, a rodent trap that contained a rodent was observed. Directly behind the trap was a potato on the floor. -In the kitchen area, to the right of the ice machine, rodent droppings were observed in the corner. During an interview on 1/21/25 at 2:05 p.m., the Dietary Manager indicated there was not a cleaning schedule for the Month of January 2025. They had switched to a new system with more detailed forms, however the new forms had not been implemented yet. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-22 · tag F0624 — isolatedPrepare residents for a safe transfer or discharge from the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident's (Resident B) medications were available, in a timely manner, for 1 of 3 residents reviewed for discharges. Findings include: The clinical record for Resident B was reviewed on 1/21/25 at 10:04 a.m. The resident's diagnoses included, but were not limited to, congestive heart failure, acute respiratory failure with hypoxia, heart disease, diabetes, hypertension and atrial fibrillation. The progress note, dated 12/28/24 at 10:31 a.m., indicated the resident was discharged from the facility to her home. The resident's medication orders were faxed to the pharmacy of choice. During an interview on 1/21/25 at 10:35 a.m., the complainant indicated the resident's medication list did not get sent to the pharmacy. Prior to the resident discharge, he asked about medications to take with her but was told it was not facility policy, but that the resident's medications were faxed to the pharmacy. He called the facility the next day and was told they would fax the medications over to the pharmacy again. That next day,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-22 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure residents' drawers were free of rodent droppings for 2 of 3 residents reviewed for sanitary environment. (Resident F and Resident G) Findings include: 1. The clinical record for Resident F was reviewed on 1/21/25 at 1:35 p.m. The resident's diagnoses included, but were not limited to, diabetes, hypertension and anemia. During an interview on 1/21/25 at 11:02 a.m., the resident indicated he believed the mouse problem had been taken care of as he had not seen any lately. During an observation on 1/12/25 at 11:03 a.m., the following concerns were observed: - The top drawer of the resident's night stand had multiple storage containers with snacks and crackers. The bottom of the drawer was observed with rodent droppings. - The middle drawer of the night stand was empty with rodent droppings on the bottom. - The bottom drawer of the night stand contained personal hygiene items. Rodent droppings were observed on the bottom. - The top drawer of the chest was observed with storage containers with snacks. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow guidelines related to dishwasher temperatures for 2 of 2 kitchen observations, infection control during dining for 1of 3 dining observations, and to maintain a resident snack refrigerator in a sanitary manner for 1 of 2 resident snack refrigerators observed. This deficient practice had the potential to affect 55 of 55 residents who received food from the kitchen. Findings include: 1. During an observation and interview of the dishwasher on 12/03/24 at 9:30 A.M., the Dietary Manager indicated there was a wash and rinse valve to monitor for the temperatures on the dishwasher. The valve indicated the rinse temperature was at 140 degrees. The Dietary Manager indicated the dishwasher temperature for the rinse cycle should be 180 degrees. She was going to have the staff stop washing the dishes and have the Maintenance Director look at it. The Dish Machine daily Temperature Record Logs for November 2024 indicated from 11/01/24 through…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-10 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the equipment in resident rooms were kept clean for 6 of 26 rooms reviewed for environment. (Rooms 105, 107, 111, 114, 115, and 120) Findings include: During a tour of the facility on 12/4/24 at 11:00 a.m., the 100 and 200 Halls had several rooms observed to have a black spotty substance covering most of the slats on the following heater vents: - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. During an interview on 12/4/24 at 9:46 a.m., Resident 47 indicated she had black mold on her heater vents. When she woke up in the mornings the first thing she did was to start sneezing. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete discharge Minimum Data Set (MDS) assessments for 2 of 19 MDS's reviewed. (Residents 14 and 25) Findings include: 1. The clinical record for Resident 14 was reviewed on 12/09/24 at 10:23 A.M. The resident's census indicated they were admitted to the facility on [DATE] and discharged with no anticipated return on 07/01/24. The MDS listings lacked a completed discharge assessment. 2. The clinical record for Resident 25 was reviewed on 12/09/24 at 10:26 A.M. The resident's census indicated they were admitted to the facility on [DATE] and discharged with no anticipated return on 07/01/24. The MDS listings lacked a completed discharge assessment. During an interview on 12/09/24 at 10:52 A.M., the MDS Coordinator indicated if a resident discharged from the facility then a discharge assessment should be completed. The discharge assessments for residents 14 and 25 had been missed and should have been completed. The current facility policy titled,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-10 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to prevent a skin impairment for 1 of 17 residents reviewed for quality of care. (Resident 3) Findings include: During and observation on 12/06/24 at 1:47 P.M., Resident 3 was assisted with peri care. The resident had a bandage to the right bottom of the buttock. The dressing was clean and dry. The bandage was dated 12/06/24. The clinical record for Resident 3 was reviewed on 12/05/24 at 11:46 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/08/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, anemia, hemiplegia/hemiparesis, and depression. The resident was always incontinent of bowel and bladder. A Progress Note, dated 10/23/24 at 12:53 A.M., indicated a Certified Nurse Aide (CNA) had reported an open area to the resident's upper right posterior thigh from the brief. The area measured 2.5 centimeters (cm) X (by) 1.0 cm X 0.2 cm. The area was cleansed and covered with a foam dressing. Wound Care was notified, and they were awaiting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-10 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the facility failed to ensure the proper dose was administered related to priming the needel for the insulin kwikpens and following the physician's order for 2 of 2 resident's observed for pharmacy services. (Residents 160 and 56) Findings include: 1. During an observation on 12/5/24 at 11:00 a.m., LPN (Licensed Practical Nurse) 10 obtained Resident 160's blood sugar by glucometer. The blood sugar reading was 263 mg/dL (milligrams per deciliter). The LPN applied the needle to the Humalog kwikpen and dialed the pen to 3 units. She did not prime (dial the kwikpen to 2 units and press to remove air) the needle prior to administering 3 units of Humalog into the resident's right upper arm. During an interview on 12/5/24 at 11:15 a.m., LPN 10 indicated she had administered 4 units, then corrected herself and confirmed she had only administered 3 units of insulin to the resident. The LPN planned to administer another unit. During an observation on 12/5/24 at 11:20 a.m., LPN 10 applied the needle to the Humalog kwikpen. The LPN administered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents meal consumptions were documented, per the plan of care, for 2 or 3 residents reviewed for medical records. (Resident B and Resident C) Findings include: 1. The clinical record for Resident B was reviewed on 10/11/24 at 12:27 p.m. The resident's diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease and depression. The care plan, dated 7/1/20, indicated the resident required setup assistance with meals and to monitor/document percentage eaten. Review of the August 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 8/01/24, the resident's consumption for dinner was not documented. - On 8/02/24, the resident's consumption for dinner was not documented. - On 8/05/24, the resident's consumption for dinner was not documented. - On 8/06/24, the resident's consumption for dinner was not documented. - On 8/07/24, the resident's consumption for lunch was not documented. - On 8/09/24, the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure residents (Resident B and Resident C) were served meals on appropriate dinner ware for 2 of 3 residents reviewed for resident rights. Findings include: 1. The clinical record for Resident B was reviewed on 2/12/24 at 1:22 p.m. The diagnosis included, but was not limited to, left sided hemiplegia and hemiparesis. On 2/12/24 at 1:15 p.m., the resident was observed resting in bed with her eyes open, call light in reach and lunch at bedside in a styrofoam container with plastic eating utensils. Meals had been served in styrofoam for well over a year. She just thought that was how all the meals were served. She thought it would be wonderful if they would serve the meals on regular plates with good silver ware. She could not cut anything up without the plastic utensils breaking. She only had one good hand and the Styrofoam makes it harder to eat. During an interview on 2/13/24 at 10:45 a.m., the Assistant Dietary Manager indicated they were using Styrofoam because the company, whom they contracted with, left.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure quarterly smoking assessments were completed for 2 of 3 residents reviewed for quality of care. (Residents B and C) Findings include: 1. The clinical record for Resident B was reviewed on 2/12/24 at 1:22 p.m. The diagnoses included, but were not limited to, left sided hermiplegia and hemiparesis, bipolar and major depressive disorder. The care plan, dated 12/21/21, indicated the resident required supervision with smoking and to update the smoking assessment quarterly and as needed. Review of Resident B's smoking risk assessments indicated a quarterly assessment was last completed on 8/17/23. The clinical record lacked documentation of a quarterly assessment for November 2023. During an interview on 2/12/24 at 2:48 p.m., the Director of Nursing indicated when the quarterly assessments were set up in the new system, the smoking assessments were not included. RN (Registered Nurse) 3 indicated per facility policy, smoking assessments were to be completed quarterly. 2. The clinical record for Resident C was reviewed on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner for 3 of 3 observations. This deficient practice had the potential to affect all 57 residents currently residing at the facility. Findings include: 1. During the initial tour of the kitchen on 10/23/23 at 9:30 a.m., the following concerns were observed: - There was a heavy buildup of white under the dishwasher and dirty dish counter. - The back splatter guard of the stove had a moderate buildup of brown and black grease to it. - There was a coating of brown substance on the top of the flat top griddle. Dietary [NAME] 4 indicated That needs to be cleaned. We don't use that that often. We set stuff on it and that makes it turn brown. We use it for grilled cheeses sometimes. It was cleaned about a week ago. - There was a heavy buildup of grease on the table under the griddle. The cook indicated she needed to clean that up. - There was a moderate buildup of grease and grime on the side of the Vulcan oven as well as the wall behind, and the floor underneath of it. - There was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-30 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were offered pneumococcal vaccinations as recommended by the CDC (Centers for Disease Control) for 4 of 5 residents reviewed for pneumococcal immunizations. (Residents 31, 32, 41, and 50) Findings include: 1. The record for Resident 31 was reviewed on 10/23/23 at 10:40 a.m. The record indicated Resident 31 was [AGE] years old and had received Prevnar 13 (PCV13 (pneumococcal conjugate vaccine) on 11/6/19. Upon admission on [DATE], the resident's Responsible Party signed the consent form declining the administration of the pneumococcal vaccine. No further attempts were made since 7/14/21 for the resident to receive the recommended second dose of either PCV20 or PPSV23 (pneumococcal polysaccharide vaccine) after one year as recommended by the current CDC guidance. 2. The record for Resident 32 was reviewed on 10/23/23 at 10:50 a.m. The record indicated Resident 32 was [AGE] years old and had received one dose of a pneumococcal vaccine on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-30 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure adequate maintenance of essential kitchen equipment for 3 of 3 observations. This deficient practice had the potential to affect all 57 residents currently residing at the facility. Findings include: During the initial tour on 10/23/23 at 9:30 a.m., in the walk-in freezer there was a heavy accumulation of ice on the floor spanning from wall to wall. Maintenance Assistant 6 was using a long-handled dustpan to break up and scoop up the ice before depositing it into a 13-gallon trash can which was halfway full of ice. The broken ice remaining on the floor was approximately one-quarter of an inch thick and appeared to have accumulated out approximately 4 feet from the fan at the back of the fridge. There was a heavy stream of water flowing from the condenser pipe and onto the floor. Maintenance Assistant 6 indicated he wasn't sure how long the ice had been accumulating. He had been notified on the radio of the issue just a few minutes prior to the observation. During an interview on 10/23/23 at 9:45 a.m., the Dietary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure notification to the representative of a resident's change in condition for 1 of 22 residents reviewed for notification of changes. (Resident 54) Findings include: The record for Resident 54 was reviewed on 10/30/23 at 8:39 a.m. The diagnoses included, but were not limited to, muscle weakness, hypertension, dementia, Alzheimer's with late onset, and chronic kidney disease. The activities note, dated 6/27/23 at 10:28 a.m., indicated the resident was alert and made all her needs known. She sat up in her wheelchair most days in the hallway by the nurses' station and talked to most everyone. She could wheel herself around freely. She would do arts and crafts and play bingo and listen to music. She would come into the activities office and get a snack and hang out. The activities note, dated 9/14/23 at 12:14 p.m., indicated the resident seemed confused most days, however she would sit in the hall by the nurses' station and talk to everyone. She would come into the activities office and hang out and liked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure a resident's treatment was timely for 1 of 5 residents reviewed for Quality of Care. (Resident 31) The record for Resident 31 was reviewed on 10/26/23 at 9:07 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease, other skin changes, and obesity. The fax sheet cover, dated 6/17/23, indicated the facility sent a fax for Resident 31 of a urinalysis and culture results to the physician. The staff inquired if the physician wanted to continue antibiotics and informed the physician the resident was having symptoms of a yeast infection. On 6/19/23, the physician responded with a fax. The fax was dated as received on 6/19/23 at 4:51 p.m. and indicated to continue the antibiotics and to start Diflucan (antifungal) 150 mg (milligram), one time. The record lacked documentation indicating the faxed order (dated 6/17/23) was received and the resident received the treatment for a yeast infection in a timely manner. The resident was not treated for five days (dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2023-10-30 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate documentation of the MDS (Minimum Data Set) assessment for Section N for antiplatelet therapy for 9 of 24 residents whose MDS records were reviewed for accuracy. (Residents 58, 31, 57, 51, 53, 28, 38, 20, and 10) Findings include: 1. The record for Resident 58 was reviewed on 10/25/23 at 3:08 p.m. The diagnoses included, but were not limited to, cerebrovascular disease, hemiplegia and hemiparesis affecting the left dominant side, and immobility syndrome. The physician's orders, dated 9/1/23, indicated the resident received aspirin 81 mg (milligram) and clopidogrel 75 mg, once daily. The admission MDS assessment, dated 9/7/23, indicated the resident received an anticoagulant 6 days per week. The assessment indicated for antiplatelet therapy staff would check the form indicating if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SEACOAST OF CLARKSVILLE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 09/30/2022 |
| FLORES, MARC | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/22/2022 |
| BARTLE JR, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/30/2022 |
CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Indiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 155191. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.